Every finding on record at Caresouth HHA Holdings of Lexington, LLC

An onsite, unannounced recertification survey was conducted 8/19/24-8/21/24.No deficiencies to the Emergency Preparedness Plan were identified.

An onsite, unannounced recertification survey was conducted 8/19/24-8/21/24. Standard level deficiencies to Medicare CoPs were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy, home visits, and interviews with patients and staff the Plan of Care [POC] failed to include all/correct/current medications the patient was using for 4 of 17 patients [#7, 8, 9, 17]. The findings included: The policy, Medications [revised date 6/24/24], was provided by the area vice president on 8/21/24 at 8:25 am. The policy states, “...The clinical record includes appropriate physician orders for all medications prescribed by the physician...” 1. Patient # 7 had a Start of Care [SOC] date of 1/25/24 with admitting diagnoses of type 2 diabetes with diabetic peripheral angiopathy without gangrene [blood vessel disease that occurs when high blood sugar levels damage cells in the blood vessels], chronic kidney disease [diabetes damages the blood vessels in the kidneys that filter waste from the blood], and chronic systolic [congestive] heart failure [heart stops pumping adequately]. Review of the Plan of Care [POC] for the certification period 7/23/24-9/20/24 included orders for SN [skilled nursing] 1 time a week for 3 weeks and PT [physical therapy] 2 times a week for 3 weeks with a supplemental order written on 8/12/24 for PT to see the patient 2 times a week for 6 weeks. On 8/20/24 at approximately 1 pm a joint visit was made the PTA # 1. During that visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed diflorasone 0.05% topical ointment [corticosteroid indicated for inflammatory and pruritic manifestations] use every 6 hours PRN [as needed] to the neck. During an interview with the patient, the patient stated he had never used the diflorasone cream. Eliquis [anticoagulant] 5 mg take 1 capsule 2 times a day was also listed on the medication profile. During the interview with the patient, he stated he had been switched to Xeralto 15 mg each day and he no longer used the Eliquis. Famotidine [used for reflux] 20 mg take 2 times a day was also on the medication profile. During an interview with the patient, he stated he had never used the medication. Ipratropium 0.5 mg-albuterol 3 mg [2.5 mg base]/3 ml nebulization solution take 3 ml every 8 hours as needed for shortness of breath was also included on the medication profile. The patient stated he used a “puffer” when he needed one but did not use a nebulizer. Lorazepam [used for anxiety] 0.5 mg take 1 every 8 hours as needed for anxiety was included on the medication profile. The patient advised the surveyor he no longer used this and didn’t need it after he had surgery at the beginning of the year. The medication profile also listed Tresiba insulin 100 units per ml take 30-50 units every pm. The patient stated, “I check my blood sugar, and I gage the amount of insulin to give myself based on the blood sugar reading. I usually give myself between 8-15 units.” During an interview with PTA # 4 after the visit, it was confirmed the medication on the POC were incorrect. 2. Patient # 8 had a Start of Care date of 6/13/24 and an admitting diagnosis of infection/inflammation reaction due to internal fixation of left tibia [shin bone]. Review of the Plan of Care [POC] for the certification period 8/12/24-10/10/24 included orders for SN [skilled nursing] 3 times a week for 3 weeks, 2 times a week for 1 week, 3 times a week for 4 weeks, 2 times a week for 1 week. On 8/20/24 at approximately 1 pm a joint visit was made with LPN # 2. During the visit, a medication review was completed using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Cyclobenzaprine [muscle relaxer] 5 mg tablet. Take 1 tablet 3 times a day. During an interview with the patient, she stated she took the medication 2 times per day. The medication profile listed Cipro [antibiotic] 500 mg 2 times per day. During the interview the patient stated she no longer takes Cipro but was taking Bactrim [antibiotic] 800-120 mg 2 times per day. The Bactrim was not listed on the medication profile. The medication profile listed Metronidazole [antibiotic] 500 mg 2 times per day. The patient reported she had completed this medication “a few weeks back”. During the visit, LPN # 2 completed a wound vac change to the left lower leg. The LPN applied santyl [debriding agent] to the wound bed during the dressing change. The medication profile did not include santyl. During an interview with the agency area vice president on 8/21/24 at approximately 2 pm, the VP [vice president] confirmed the POC did not include the correct/current medications. 3. Patient # 9 had a Start of Care date of 6/23/24 and an admitting diagnosis of other sequelae of cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 6/23/24-8/21/24 included orders for PT [physical therapy] 3 times a week for 1 week, 2 times a week for 7 weeks. On 8/20/24 at approximately 3 pm a joint visit was made with PT # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Lipitor [high cholesterol] 10 mg take every 12 hours. Review of the directions on the bottle dated 6/8/24 revealed the patient should only take the medication 1 time per day. The patient reported she takes the medication at bedtime only. The medication profile listed Magnesium Oxide [supplement] 400 mg take 1 tablet daily. During an interview with the patient she reports, “I don’t take those anymore.” The medication profile listed Pantoprazole [reflux] 20 mg take 1 tablet 2 times a day. During the interview with the patient she stated, “I don’t take that pill anymore.” During an interview with the agency area vice president [VP] on 8/21/24 at approximately 3 pm, the VP confirmed the medications were not correct on the POC. 4. Patient # 17 had a Start of Care date of 8/2/24 and an admitting diagnosis of sepsis due to methicillin resistant staphylococcus aureus [blood infection due to bacteria]. Review of the Plan of Care [POC] for the certification period 8/2/24-9/30/24 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 5 weeks, 1 time a week for 3 weeks and “SN to ...flush PICC [peripherally inserted central catheter] with 10 ml normal saline, flush with 5 ml of 100 unit/ml heparin [blood thinner...Insulin Lispro 100 unit/ml subcutaneous pen take 4 times daily per sliding scale...” Review of the POC revealed the normal saline nor the heparin were included on the POC. Further review revealed the dosage related to the sliding scale insulin was not included on the POC. During an interview with the area vice present on 8/21/24 at approximately 3:30 pm she confirmed the medications [normal saline and heparin] and the dosage of the insulin should have been included on the POC.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy, and staff interviews the SN [skilled nurse] developed a Plan of Care [POC] with orders to change a urinary catheter monthly for 1 of 1 patients [#14] who saw a urologist for catheter changes. The findings included: The policy, Physician's Role [revised 10/18/23], was provided by the area vice president on 8/20/24 at approximately 8:10 am. The policy stated, "...Plan of care is a written plan developed with the participation of professional staff and the patient, in consultation and authorized by the physician that supports the patient's medical, nursing and psychosocial needs..." Patient # 14 had a Start of Care date of 1/10/24 with admitting diagnoses of pressure ulcer of sacral [at the base of the spine] stage 3 [full thickness loss of skin that extends to the subcutaneous tissue], pressure ulcer of left buttock, stage 3, and encounter for fitting and adjustment of urinary device. Review of the Plan of Care [POC] for the certification period 1/10/24-3/9/24 included orders for SN [skilled nursing] 2 times a week for 9 weeks and “skilled nurse for insertion of foley catheter using catheter 16 fr [french] 10 cc balloon, nurse to change Q [every] month and PRN [as needed] …” Review of the clinical record revealed no evidence the foley catheter was changed from 1/10/24-3/9/24. Further review of the clinical record revealed the POC from 7/8/24-9/5/24 included orders for SN 3 times a week for 8 weeks, 1 time a week for 1 week and “skilled nurse for insertion of foley catheter using catheter 16 fr 10 cc balloon, nurse to change Q [every] month and PRN [as needed] ...”. The catheter was not changed during the month of July, and the catheter had not been changed as of 8/19/24. During an interview with the area vice president of the agency on 8/21/24 at 3 pm, the VP [vice president] stated, “Our nurses do not change the catheter. The patient goes to the urologist and went to the urologist yesterday and had the catheter changed. I don’t know why it was included as a physician’s order on the POC.”

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the skilled nurse failed to complete wound care as ordered for 1 of 1 patient with an infected wound [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 10/7/23 with an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot with fat layer exposed, and non-pressure chronic ulcer of left heel and midfoot with fat layer exposed. Review of the Plan of Care [POC] for the certification period 10/7/23-12/5/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 weeks, 2 times a week for 4 weeks, 1 time a week for 1 week “Skilled nurse to perform wound care to pressure ulcer/pressure injury to left heel. Cleanse with wound cleanser and pat dry. Apply hydrofiber silver. Cover with gauze using clean/aseptic technique. Wrap with roll gauze/tape...” RN # 8 completed the admission visit on 10/7/23 and documented wound care to the left heel was completed per the physician’s order. The RN also documented a stage II pressure ulcer to the left distal plantar [the bottom of the foot] with measurements of 0.5x2.5x0.1. RN # 8 documented, “...first aid care only pending orders from physician. Cleansed with NS [normal saline and applied dry dressing...” Further review of the clinical record revealed the patient received SN visits on 10/10/23, 10/12/23, 10/17/23 and 10/19/23 with no specific wound care completed to the left plantar area which was identified by RN # 8 at the time of admission. On 10/19/23, LPN # 5 documented the following information, “..._____ from ____ [name of the wound clinic] returned my call yesterday and said because she hasn’t been seen since 9/14/23 provider wouldn’t give any orders...” LPN placed a dry dressing on the area. The patient was seen at the would clinic on 10/24/23 and the clinical record included an order to “Cleanse wound [left plantar] with wound cleanser. Apply calcium alginate with silver, cover with 4x4 gauze, roll gauze and secure with tape. Change dressing every third day...” Further review of the clinical record revealed the patient received 7 SN visits from 10/26/23-11/21/23 and the orders from the wound clinic were never written as an order. The patient continued to receive a dry dressing to the left plantar area from the time of admission until the patient was discharged to the hospital on 11/23/23. During an interview with the area vice president [VP] on 8/21/24 at approximately 3:30 pm, the area VP stated, “The patient never did get the treatment to the wound that was ordered at the wound clinic."

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and staff interviews, the skilled nurse educated a patient on taking a medication without a physician's order for 1 of 1 patient with and infected wound [#1]. The findings included: The policy, Physician's role [revised date 10/18/23], was provided by the area vice president on 8/20/24 at approximately 8:15 am. The policy stated, "...Staff develops and maintains the plan of care in consultation with the physician and follows established procedures..." Patient # 1 had a Start of Care [SOC] date of 10/7/23 with an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot with fat layer exposed, and non-pressure chronic ulcer of left heel and midfoot with fat layer exposed. Review of the Plan of Care [POC] for the certification period 10/7/23-12/5/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 weeks, 2 times a week for 4 weeks, 1 time a week for 1 week. Review of the clinical record revealed LPN # 5 conducted a routine visit on 10/31/23 and documented the following information, “...patient informs she had xray left foot plantar wound and cultures of wound obtained with last visit at ____ [wound clinic]…Patient informs she is on and ABX [antibiotic therapy]…medication list updated...Educated patient needs to take probiotic because ABX will be long term and will need to “protect” digestive tract...” Further review of the clinical record revealed no order for a probiotic or any evidence the LPN notified the physician prior to advising the patient to use a probiotic. During an interview with the agency vice president [VP] on 8/21/24 at approximately 3:30 pm, the VP advised there was no order or a probiotic

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy, direct observation and staff/patient interviews the physical therapy assistant failed to notify the physician of a change in condition for 1 of 2 patients who received dialysis [#7]. The findings included: The policy, Coordination of Care [revised 10/18/23], was provided by the area vice president on 8/20/24 at approximately 8 am. The policy stated, " Promptly alert the physician to any change which suggest a need to modify the plan of care..." Patient # 7 had a Start of Care [SOC] date of 1/25/24 with admitting diagnoses of type 2 diabetes with diabetic peripheral angiopathy without gangrene [blood vessel disease that occurs when high blood sugar levels damage cells in the blood vessels], chronic kidney disease [diabetes damages the blood vessels in the kidneys that filter waste from the blood], and chronic systolic [congestive] heart failure [heart stops pumping adequately]. Review of the Plan of Care [POC] for the certification period 7/23/24-9/20/24 included orders for SN [skilled nursing] 1 time a week for 3 weeks and PT [physical therapy] 2 times a week for 3 weeks with a supplemental order written on 8/12/24 for PT to see the patient 2 times a week for 6 weeks. On 8/20/24 at approximately 1 pm a joint visit was made the PTA # 1. During the visit the patient explained he had had dialysis the previous day on 8/19/24. He proceeded to tell the clinician the dialysis nurse was unable to access his graft for the dialysis and when she removed the needle he began to bleed “a lot”. He stated the nurse held firm pressure on his right antecubital area for a significant length of time. He reported while she was holding the pressure he felt “a lot of pain.” He then showed the PTA his arm. His right arm was swollen tightly and had extensive purple bruising. The patient reported he was unable to extend his arm completely. The patient stated the arm was painful. During the visit, the PTA did not examine his arm. Review of the clinical record revealed the PTA did not contact the physician or the PT to report the changes in the patient’s right arm. During an interview on 8/21/22 at approximately 11 am, the PTA advised the incident happened while he was at dialysis, and he was scheduled to go back to dialysis on 8/21/24 and she felt the dialysis nurse would assess his right arm. On 8/21/24 at approximately 3:30 pm the area vice president confirmed there was no coordination with the physician or the PT regarding the patient’s right arm.

A recertification survey was conducted 1/31/22-2/3/22 no deficiencies to the Emergency Preparedness program was identified.

An unannounced onsite recertification survey was conducted 1/31/22 - 2/3/22. Standard level deficiencies to the Medicare CoP were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, virtual visit observation, clinical record review, interviews with patient/caregiver and staff, the Plan of Care did not include the correct/current medications the patient was using for 5 of 18 records [# 11, 15, 17, 5, 12]; failed to include the oxygen rate for 1 of 6 active records [without visits] [#1]; failed to include the use of a incentive spirometry for 1 of 6 active records [#1] without a visit. The findings included: 5A. Patient #1 was admitted on 12/21/21 with a diagnosis of encounter for attention to tracheostomy. The Plan of Care (POC) for 12/21/21-2/18/22 included orders for skilled nursing two times per week for 3 weeks, then weekly for six weeks. The POC “Equipment and Supplies” included an “oxygen concentrator… nasal cannula…oxygen supplies”. The initial assessment completed on 12/21/21 revealed the patient required oxygen. The POC did not include oxygen rate or frequency. An interview with LPN #1 on 2/2/22 at 1:15 p.m. revealed, “She gets oxygen through her trach [tracheostomy] at night.” An interview with the agency director on 2/2/22 at 1:30 p.m. confirmed the oxygen was not included on the POC. 5B. Patient #1 was admitted on 12/21/21 with a diagnosis of encounter for attention to tracheostomy. The Plan of Care (POC) for 12/21/21-2/18/22 included orders for skilled nursing two times per week for 3 weeks, then weekly for six weeks. A visit was conducted on 1/7/22 by LPN #1. The visit note stated, “Educated importance coughing and deep breathing exercises using incentive spirometer…” The POC did not included incentive spirometry. An interview with the agency director on 2/2/22 at 1:30 p.m. confirmed incentive spirometry was not included on the POC. 6. Patient #12 was admitted on 10/18/21 with a diagnosis of a right femur fracture. The Plan of Care (POC) for 12/17/21-2/14/22 included orders for skilled nursing weekly for three weeks and physical therapy two times per week for three weeks, then weekly for three weeks. A virtual home visit was conducted on 2/1/22 at 9:15 a.m. with RN #7. The agency provided the Client Medication Report and the MAR [medication administration record] from the assisted living facility (ALF). The following discrepancies were identified: Acetaminophen 325 mg (2 tablets) every 4 hours as needed for pain was on the agency Client Medication Report. The ALF MAR was for 500 mg (1 tablet) three times per day with the order written on 12/8/21.Simvastatin 20 mg daily for cholesterol was on the agency Client Medication Report. The ALF MAR was for 10 mg daily with the order written on 11/23/21.Metoprolol Tartrate 25 mg daily for blood pressure was on the agency Client Medication Report. The ALF MAR did not include Metoprolol Tartrate.Miralax 17 gm daily for constipation was on the agency Client Medication Report. The ALF MAR did not include Miralax.Risperidone 0.5 mg twice daily for mood was on the agency Client Medication Report. The ALF MAR did not include Risperidone. Biofreeze (pain) was omitted from the agency Client Medication Record. The ALF was administering Biofreeze 4% topically to each knee 3 times per day with the order written on 12/8/21.Pantoprazole (stomach) was omitted from the agency Client Medication Record. The ALF was administering 40 mg daily with the order written on 11/23/21.Senna Plus (laxative) was omitted from the agency Client Medication Record. The ALF was administering Senna Plus 8.6-50 mg (2 tablets) every other day with the order written on 1/12/22.Sertraline (antidepressant) was omitted from the agency Client Medication Record. The ALF was administering 25 mg daily with the order written on 11/24/21.Vitamin B-12 (supplement) was omitted from the agency Client Medication Record. The ALF was administering 1,000 mcg daily.Lorazepam (antianxiety) was omitted from the agency Client Medication Record. The ALF was administering 0.5 mg topically every 8 hours as needed for agitation/restlessness.Preparation H (hemorrhoid cream) was omitted from the agency Client Medication Record. The ALF was administering Preparation Cream externally to rectum twice daily as needed for hemorrhoids. An interview with RN #7 was conducted on 2/2/22 at 2:20 p.m. The RN stated, “I don’t know if we didn’t get those when she discharged from the hospital. I am not sure when we dropped the ball on that…Our process failed somewhere on that.” The policy, Physician’s role [3/1/19], was provided by the agency administrator on 2/2/22 at approximately 9:00 am. The policy stated, “…The agency obtains complete orders for care. The orders will include…Prescribed medications with dose, route and frequency of the administration…” 1. Patient # 11 had a Start of Care [SOC] date of 12/2/21 and admitting diagnoses of Aftercare Following Surgery for Neoplasm and Secondary Malignant Neoplasm of Brain. A review of the Plan of Care [POC] for the certification period 1/31/22 to 3/31/22 revealed orders for OT [occupational therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 week. On 2/1/22 a virtual visit was conducted with OT # 16. During the visit a medication review was conducted using the Client Medication Report provided by the agency. The follow discrepancies were noted: The medication report listed Levetiracetam [seizure medication] 500 mg daily. During an interview with the patient after the visit the patient reported the actual dose she was taking was 500 mg 2 times per day with an effective date of 12/13/21. During an interview with the agency administrator on 2/2/22 at approximately 4:00 pm the administrator confirmed the POC did not include the current medications. 2. Patient # 15 had a Start of Care [SOC] date of 3/30/21 and admitting diagnoses of Chronic Obstructive Pulmonary Disease [COPD], Hypertensive Heart Disease with Heart Failure and Acute on Chronic Diastolic Heart Failure. The Plan of Care [POC] for the certification period 1/24/22 to 3/24/22 included orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every 2 weeks for 4 weeks, 1 time a week for 1 week. On 2/1/22 at approximately 3:00 pm a joint visit [virtual] was made with LPN # 1. During the visit a medication review was conducted using a Client Medication Report provided by the agency. The following discrepancies were noted: Metoprolol Tartrate [cardiac medication] 25 mg 1 tablet two times per day was listed on the medication report. During the visit the patient reported the current dose of the medication was ½ a tablet two times per day with a start date of 1/6/22. The medication record indicated the patient was taking Prednisone [steroid] 20 mg tablet-take 2 tablets every morning until better then taper to ½ tablet every other day. During an interview with the patient on 2/1/22 the patient stated, “I have already completed that medication. The doctor ordered it the last time I was sick.” During an interview with the agency administrator on 2/2/22 at approximately 4:00 pm the administrator confirmed the POC did not include the current medications. 3. Patient # 17 had a Start of Care [SOC] date of 1/15/22 and admitting diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation, Peripheral Vascular Disease, Type 2 Diabetes with Diabetic Peripheral Angiopath [sic] without Gangrene and Type 2 Diabetes Mellitus with Hyperglycemia. A review of the Plan of Care [POC] for the certification period 1/15/22 to 3/15/22 revealed orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 1 week, 1 time a week for 7 weeks. On 2/2/22 at approximately 9:30 am a virtual home visit was conducted with RN # 9. During the visit a medication review was conducted using a Client Medication Report provided by the agency. The follow discrepancies were noted: The Medication Report listed the following medications: Zinc [supplement] 50 mg take 1 tablet daily. Tramadol [pain] 50 mg 2 times daily. Trazodone [antidepressant] 50 mg. Take 1 tablet at bedtime. During an interview with the patient he stated, “I haven’t taken any of those medicines since I came home from the hospital.” The medication report did not include Humalog [insulin]. The patient stated, “I take Humalog 6 units at breakfast, 8 units at lunch and 10 units at supper. I have been on Lantus and Humalog for a long time.” During an interview with RN # 9 on 2/2/22 at approximately 3:20 pm the RN stated, “No the POC did not have the updated medicines listed.” 4. Patient # 5 had a Start of Care [SOC] date of 12/10/21 and admitting diagnoses of Encounter for Change or Removal of Nonsurgical Wound Dressing, Pressure Ulcer of Sacral Region, Unstageable and Pressure Ulcer of Right Ankles, Stage 2. A review of the Plan of Care [POC] for the certification period 12/10/21 to 2/7/22 revealed an order for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 3 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks. A review of the clinical record PT # 4 completed the admission assessment on 12/10/21. A review of the medication profile revealed the following entry, “Novolog Flexpen U-100 Insulin as needed/PRN “. There was no dosage noted on the medication profile. PT # 4 was not available for interview. An interview was conducted with the agency administrator on 2/2/22 at 1:15 pm. During the interview the administrator confirmed the POC was not complete related to the missing insulin dosage.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to follow the Plan of Care [POC] related to reporting weights outside the given parameters for 1 of 6 active records [with no visit] [#2]; failed to obtain O2 saturation readings for 3 of 18 records [# 2, 7, 15]; failed to perform wound care in accordance with the POC for 2 of 18 records [#7, 17]. The findings included: 1A. Patient # 2 had a Start of Care [SOC] date of 12/16/21 and an admitting diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure. A review of the Plan of Care [POC] for the certification period 2/16/21 to 2/13/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks and “Licensed professional to report vital signs falling outside the following established parameters…weight less than 120 or greater than 125…” A review of the clinical record revealed on 12/16/21 RN # 3 documented a weight of 119 pounds. There was no evidence the physician was notified of the weight. RN # 3 was not available for interview. An interview was conducted with the agency administrator on 2/2/22 at 1:15 pm. During the interview the agency administrator reported, “I can’t find any documentation that shows she notified the physician of the weight.” 1B. Patient # 2 had a Start of Care [SOC] date of 12/16/21 and an admitting diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure. A review of the Plan of Care [POC] for the certification period 12/16/21 to 2/13/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks and “…May perform ox saturation level at evaluation visit and PRN [as needed] for signs and or symptoms of possible respiratory complications…” A review of the clinical record revealed the following documentation by LPN # 1: 12/30/21- “…Lungs with poor air exchange; with fine crackles throughout all lung fields…”, 1/4/22- “…Occasional wet nonproductive cough noted during visit…Lungs with fine crackles throughout all lung fields…”, 1/19/22 - “…Lungs with poor air exchange with fine crackles…bp [blood pressure] trending low…” There was no evidence an oxygen saturation was obtained during any of those visits made by LPN # 1. An interview was conducted with LPN # 1 on 2/3/22 at 1:00 pm. During the interview the LPN stated, “I usually did check the pulse ox on the patient. I may have forgotten to document it.” RN # 3 documented the following information during the 1/8/22 visit, “…Lungs diminished with rhonchi scattered throughout. Congested, rattly [sic] cough noted at times. SHOB [shortness of breath] with moderated exertion…” Further review of the clinical record revealed no O2 saturation was documented. RN # 3 was not available for an interview. On 1/13/22 RN # 8 documented, “…Lungs diminished with coarse breath sounds in upper lobes. Patient reports occasional productive cough for [sic] yellowish mucous [sic]…” During an interview with RN # 8 on 2/2/22 at approximately 3:30 pm the RN stated, “I should have obtained a pulse ox, that was a long time ago and I can’t remember if I did or not.” An interview was conducted with the agency administrator on 2/2/22 at approximately 1:15 pm. During the interview the administrator stated, “Yes, I would expect to always see a pulse ox on someone with lung disease.” 2A. Patient # 7 had a Start of Care [SOC] date of 10/6/21 and an admitting diagnosis of Acute Respiratory Failure with Hypoxia. A review of the Plan of Care [POC] for the certification period 10/6/21 to 12/4/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 4 weeks; ST [speech therapy] 1 time a week for 1 week, 2 times a week for 3 weeks and “…may perform O2 saturation level at evaluation visit and PRN [as needed] for signs and symptoms of possible respiratory complications or with O2…” A review of the SN visit notes for 10/9/21 revealed SN # 9 documented the following information, “…lungs congested throughout…” On 10/12/21 RN # 9 made a routine visit. RN # 9 documented the following assessment, “…Daughter states pt still has increased cpough [sic] and congestion…”A review of the clinical record revealed on the following dates ST # 10 made routine visits and documented – 10/11/21-“Patient with difficulty remaining alert and on task…patient with decreased breath sounds to bilateral lobes…patient presenting with productive cough yellow in color…” 10/28/21: “…in bed with lethargy and wet gurgly [sic] vocal quality…” There was no pulse ox documented for any of the visits. An interview was conducted with the agency administrator on 2/2/22 at 1:15 pm. During the interview the director stated, “I would expect to see pulse ox readings documented on this patient each visit.” 2B. Patient # 7 had a Start of Care [SOC] date of 10/6/21 and an admitting diagnosis of Acute Respiratory Failure with Hypoxia. A review of the Plan of Care [POC] for the certification period 10/6/21 to 12/4/21 revealed orders SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 4 weeks. On 10/12/21 a supplemental order was written that stated, “SN for wound care/bilateral heels. Cleanse wounds with NS [normal saline], apply xeroform, gauze wrap every other day.” On 10/25/21 a supplemental order was written for wound care to the right buttock to cleanse with saline and apply calcium alginate to wound bed. Change 3 times per week. A review of the clinical record revealed LPN # 11 made a routine visit on 10/22/21 and documented the following information, “Left heel- wound care not done-caregiver completed wound care. Right heel- wound care not done-caregiver completed wound care” and “Wound to right buttock-wound care not provided, caregiver completed care.” An interview was conducted with LPN # 11 on 2/2/22 at 3:30 pm. During the interview the LPN stated, “I can’t remember the wound care I done, and I can’t see the record.” An interview was conducted with the agency administrator on 2/2/22 at approximately 3:45 pm. During the interview the administrator confirmed the physician’s orders were not followed related to wound care. On 10/25/21 RN # 15 made a routine visit and documented the following wound care, “Left heel and Right heel-wet to dry dressings and covered with gauze…” RN # 15 was not available for an interview. During an interview with the administrator on 2/2/22 she confirmed the physician’s order was not followed on 10/25/21. 3. Patient # 15 had a Start of Care [SOC] date of 3/30/21 and admitting diagnoses of Chronic Obstructive Pulmonary Disease [COPD], Hypertensive Heart Disease with Heart Failure and Acute on Chronic Diastolic Heart Failure. The Plan of Care [POC] for the certification period 11/25/21 to 1/23/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and “…May perform O2 saturation level at evaluation visit and PRN [as needed] for signs and or symptoms of possible respiratory complications…” A review of the clinical record revealed the following information: 11/30/21 RN # 8 made a routine visit. RN # 8 documented, “Patient states ‘there has to be something else they can do for me’ …Lungs auscultated for [sic]some wheezing and decreased breath sounds in bilateral lobes…” On 12/22/21 LPN # 1 documented the following information, “Patient informs she [sic] is on an ABX [antibiotic]…Lungs with poor air exchange with wheezing throughout all lung fields…” On 1/4/22 RN # 3 made a routine visit and documented, “I still have a cough and all this phlegm...Lungs- wheezes/rhonchi throughout lung fields. Productive cough, thick green phlegm…” A review of the vital sign assessment revealed no pulse ox was obtained. During an interview with the agency administrator on 2/2/22 at 1:15 pm the administrator stated, “I would expect this patient to have a O2 saturation documented each visit due to her COPD.” 4. Patient # 17 had a Start of Care [SOC] date of 1/15/22 and admitting diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation, Peripheral Vascular Disease, Type 2 Diabetes with Diabetic Peripheral Angiopath [sic]without Gangrene and Type 2 Diabetes Mellitus with Hyperglycemia. A review of the Plan of Care [POC] for the certification period 1/15/22 to 3/15/22 revealed orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 1 week, 1 time a week for 7 weeks. A supplemental order was written on 1/24/22 for wound care to the left foot. The order stated, “SN to cleanse wound to left foot with wound cleanser/normal saline, Apply betadine to wound cover with allyvn [sic] foam dressing…Wound to be changed daily…” A review of the clinical record revealed LPN # 11 made a routine visit on 1/28/22. There was no assessment of the left foot and no evidence the wound care was done. During an interview with LPN # 11 on 2/2/22 at approximately 3:30 pm, the LPN stated, “I didn’t know anything about a dressing or a wound to his foot.”

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to notify the physician of a fall for 1 of 6 active records [no visit] [#5]; failed to report lethargy requiring sternal rub for 1 of 1 records with an order for speech therapy [#7]; failed to notify the physician of an allergy to a medication the patient was currently using for 1 of 1 charts [#5]; failed to notify the physician of multiple skin tears for 1 of 1 record [#8]. The findings included: 3. Patient #5 was admitted on 1/5/22 with a diagnosis of hemiplegia following a cerebral infarction (paralysis on one side after a stroke). The Plan of Care (POC) for 1/5/22-3/5/22 included orders for skilled nursing weekly for four weeks, then every other week for four weeks; and evaluation for physical therapy, occupational therapy, and speech therapy. The POC listed an allergy to aspirin. The medications on the POC included Aspirin 81 mg daily. There was no evidence the physician was notified of the allergy. An interview with the agency director on 2/2/22 at 4:00 p.m. confirmed there was no evidence the physician was notified of the patient was on a medication that was listed as an allergy. 4. Patient #8 was admitted on 9/16/21 with diagnoses of traumatic subdural hematoma without loss of consciousness, displaced fracture of the 4th metacarpal bone left hand, and a fall. The Plan of Care (POC) for 9/16/21-11/14/21 included orders for physical therapy (PT) one time for one week, two times per week for three weeks, then one time per week for two weeks. PT #12 conducted the initial assessment on 9/16/21. The assessment stated, “Multiple skin tears on B [both] knees, facial bruises, bruises on both elbows and left hand.” There was no evidence the physician was notified for treatment for the skin tears. An interview with the agency administrator on 2/2/22 at 3:30 confirmed there was no evidence of coordinating with the physician regarding treatment or a referral for skilled nursing to assess wounds. The policy, Coordination of Services [10/8/21], was provided by the agency administrator on 2/2/22 at approximately 9:00 am. The policy stated, “…The licensed professional …Notifies the physician…of significant events…” 1. Patient # 5 had a Start of Care [SOC] date of 12/10/21 and admitting diagnoses of Encounter for Change or Removal of Nonsurgical Wound Dressing, Pressure Ulcer of Sacral Region, Unstageable and Pressure Ulcer of Right Ankles, Stage 2. A review of the Plan of Care [POC] for the certification period 12/10/21 to 2/7/22 revealed an order for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week. A review of the clinical record revealed the following documentation by RN # 3, “Patient reports he has fallen twice since yesterday.” Further review of the clinical record revealed no evidence the physician was notified of the fall. RN # 3 was unavailable for interview. An interview was conducted with the agency director on 2/2/22 at 1:15 pm. During the interview the administrator confirmed there was no evidence RN # 3 contacted the physician. 2. Patient # 7 had a Start of Care [SOC] date of 10/6/21 and an admitting diagnosis of Acute Respiratory Failure with Hypoxia. A review of the Plan of Care [POC] for the certification period 10/6/21 to 12/4/21 revealed orders SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 4 weeks and ST [speech therapy] 1 time a week for 1 week, 2 times a week for 3 weeks. A review of the clinical record revealed ST # 10 made a visit on 10/25/21. Further review of the clinical record revealed the following documentation, “…______ [patient name] exhibited increased lethargy this date requiring sternal rub to participate and max verbal cues from therapist and spouse. Family reported he refused his medication the day prior and this date…Therapist noted oxygen fluctuated between 90-95 while patient was in bed sleeping…” There is no evidence the speech therapist notified the physician of her findings during this visit. An interview was conducted with ST # 10 on 2/2/22 at 3:10 pm. During the interview the ST stated, “I thought I did call and tell the doctor. It would be documented in the chart if I did.”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interviews, the agency failed to complete a transfer summary for 1 of 1 patients’ transfer to hospital (#18). Findings include: A policy, “Transfer of discharge from services” (revised 05/01/2021), was provided by the agency director on 02/02/2022 at approximately 5:00 p.m. The policy stated, “In the case of a transfer to another health care facility, the appropriate licensed professional…completes the Transfer to Inpatient Facility Assessment…Completes and sends a Transfer Summary to provide pertinent information regarding the client’s needs and plan of care when aware of the transfer within 2 business days. If the transfer is unplanned, the Agency will send a Transfer Summary to the facility within 2 business days of becoming aware of the transfer if the patient remains in the facility…” Patient #18 had a start of care date of 07/10/2020 and diagnoses of Pressure ulcer of Right hip, stage IV; Type II Diabetes Mellitus without complications, and Chronic Obstructive Pulmonary Disease. The plan of care for 01/01/2022 to 03/01/2022, included orders for skilled nursing 3 times per week for 8 weeks. It was documented by skilled nurse that multiple attempts had been made to contact the patient on 01/12/2022, 01/13/2022 and 01/18/2022, all unsuccessful. On 01/20/2022 the nurse documented patient #18 had been to the hospital then transferred to a skilled nursing care facility, there was no evidence of a transfer summary in the clinical records. In an interview with the agency administrator on 02/02/2022 at 4:45 pm, it was confirmed there was no transfer summary.

An onsite complaint investigation was conducted 6/30/21-7/2/21. The allegations were unsubstantiated but standard level deficiencies to the Medicare Conditions of Participation were identified as a result of the survey.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to follow the Plan of Care for 1 of 3 patients (#1): Findings include: Patient #1 was admitted on 2/2/20 for urinary catheter management. Diagnoses included acute cystitis with hematuria, calculus of kidney, benign prostatic hyperplasia, and bladder-neck obstruction. The Plan of Care for 4/2/20-5/31/20 included orders for skilled nursing 1 time per week for 2 weeks, every other week for 2 weeks, 1 time for 1 week, and 1 every other week for 2 weeks. There was no visit the week of 4/5/20 and no evidence of a reason for a missed visit. An interview with the agency administrator on 7/1/21 at 4:20 p.m. confirmed there was no evidence of a visit the week of 4/5/20. The Plan of Care (POC) for 6/1/20-7/30/20 included orders for skilled nursing 1 time for 1 week, 1 every other week for 2 weeks, weekly for 3 weeks, 1 every other week for 2 weeks, then 1 time for 1 week. The POC also included orders for the urinary catheter to be changed every 3 weeks and as needed. An interim order on 7/9/21 stated, “SN to change foley catheter week of 7/12/20…” A review of the record revealed there was no visit made the week of 7/12/20. The visit on 7/23/20 revealed the patient/caregiver stated, “Nobody came out to change it [urinary catheter] that week you were out sick.” The catheter was changed on the 7/23/20 visit. An interview with the agency administrator on 7/1/21 at 4:20 p.m. confirmed there was no visit or catheter change during the week of 7/12/20. The Plan of Care (POC) for 9/29/20-11/27/21 included orders for 1 visit per week for 2 weeks, 1 visit every other week for 2 weeks, 1 visit for 1 week, 1 visit every other week for 2 weeks, 1 visit per week for 2 weeks. On 10/22/21, the RN visit note stated, “SN assessed balloon on catheter and withdrew 6 cc fluid from balloon, repositioned FC [foley catheter] and tried to gently push further into bladder since catheter was leaking, then reinstilled fluid in balloon…Pt verbalized having pain when balloon deflated, catheter repositioned and balloon reinflated…SN attempted to slowly flush foley catheter with 50 cc sterile water…and had to stop due to pt c/o pain…SN called Dr. _____ office…SN received call back from ____, triage nurse and Dr. _____ office…stated to add SN visit on Friday 10/23/20 for SN to delate foley catheter balloon and try to push further into bladder, then reinflate balloon and flush foley chather with 120 cc sterile water. SN informed [triage nurse] this was already done during today’s visit and pt verbalized pain. [Triage nurse] stated regardless SN need to attempt FC flush again tomorrow…SN notified scheduler of order for SN visit tomorrow.” There was no evidence of a visit on 10/23/20. The next visit was on 10/26/20. An interview with the agency administrator on 7/1/21 at 4:20 p.m. confirmed there was no visit made on 10/23/20 as instructed by the physician’s triage nurse. The POC for 3/28/21-5/26/21 included orders for skilled nursing visits weekly for 9 weeks. There were no orders for catheter changes on the POC. A review of the record revealed a visit was not conducted the week of 4/4/21. The catheter was changed on 4/14/21 and 5/5/21. An interview with the agency administrator on 7/1/21 at 4:20 p.m. revealed there were no catheter change orders on the POC.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the agency failed to coordinate care with the physician for 1 of 3 patients (#1): Findings include: A policy, “Coordination of Services” (reviewed 10/16/20), was provided by the agency administrator on 7/2/21 at 9:00 a.m. The policy stated, “Professional staff coordinate services with the physician. Staff…Develop the plan of care in consultation with the physician and/or family, and other involved in care of the patient as appropriate.” Patient #1 was admitted on 2/2/20 for urinary catheter management. Diagnoses included acute cystitis with hematuria, calculus of kidney, benign prostatic hyperplasia, and bladder-neck obstruction. The Plan of Care (POC) for 9/29/20-11/27/20 included orders for 1 visit per week for 2 weeks, 1 visit every other week for 2 weeks, 1 visit for 1 week, 1 visit every other week for 2 weeks, 1 visit per week for 2 weeks. A visit conducted on 10/9/20 revealed “foley catheter changed for [sic] protocol, with moderate difficulty passing the prostate…Foley catheter changes for this patient is getting more difficult in the last 2 months or so and more uncomfortable for the patient. Wife is going to make an appointment with urologist to discuss suprapubic catheter.” An interview with the agency administrator on 7/1/21 at 4:20 p.m. confirmed there was no evidence the physician was notified of the difficulty with catheter changes. The Plan of Care (POC) for 11/28/20-1/26/21 included orders for skilled nursing 1 time for 1 week, 1 every 3 weeks for 6 weeks, 1 every other week for 2 weeks. A coordination note for 1/19/21 revealed “foley catheter intact and draining cloudy urine due to copious amounts of sediment in line.” There was no evidence the physician had been notified of the copious amounts of sediment. An interview with the agency administrator on 7/1/21 at 4:20 p.m. confirmed that was no evidence that the physician was notified of the finding. The Plan of Care for 1/27/21-3/27/21 included orders for skilled nursing visits weekly for 8 weeks. On 2/24/21, the nurse stated, “Noted thick drainage from penis with flushing cath. Spouse states he had drainage alot [sic]. She states she tells MD this with every visit.” There was no evidence the nurse notified the physician of the drainage. An interview with the agency administrator on 7/1/21 at 4:20 p.m. confirmed there was no evidence of physician notification.